Ann Nucl Med (2012) 26:147–163
DOI 10.1007/s12149-011-0546-3

ORIGINAL ARTICLE

The agreement of left ventricular function parameters
between 99mTc-tetrofosmin gated myocardial SPECTand gated myocardial MRI
Yasuyoshi Kuroiwa • Shigeki Nagamachi • Tosiaki Miyati • Kennichirou Yamaguchi •Ryuichi Nishii • Noriyuki Kuga • Toshiya Azuma • Hideo Arita • Masaji Maeda •Shozo Tamura • Keiichi Kawai

Received: 24 April 2011 / Accepted: 10 October 2011 / Published online: 12 November 2011Ó The Japanese Society of Nuclear Medicine 2011

Abstract
Objective The aim is to compare and evaluate theagreement of quantification of left ventricular functionalparameters obtained by two different methods, 99mTctetrofosmin gated myocardial perfusion SPECT (MPS) andcardiac magnetic resonance imaging (CMR).
Methods Ten healthy male volunteers participated. Gated
MPS data were acquired using 32 frames, which were also
combined into 16- and 8-frame data set for the investigation. Gated CMR data were acquired using 8, 16 and
32-frame for the different sets. All examinations wereconducted in resting and at exercise conditions. Quantitative measurements of end-diastolic volume (EDV), endsystolic volume (ESV), left ventricular ejection fraction(LVEF), peak ejection rate (PER), peak filling rate (PFR)
and time to peak filling (TTPF) were done for each study,
Electronic supplementary material The online version of thisarticle (doi:10.1007/s12149-011-0546-3) contains supplementarymaterial, which is available to authorized users.
Y. Kuroiwa  M. Maeda
Department of Radiological Technology, Koga General
Hospital, Miyazaki, Japan
Y. Kuroiwa  T. Miyati  K. Kawai
Division of Health Sciences, Graduate School of Medical
Science, Kanazawa University, Kanazawa, Ishikawa, Japan
S. Nagamachi (&)  K. Yamaguchi  R. Nishii  N. Kuga T. Azuma  H. Arita  S. Tamura
Department of Radiology, School of Medicine,
Miyazaki University, 5200 Kihara, Kiyotake, Miyazaki,
Miyazaki 889-1692, Japane-mail: snagama@med.miyazaki-u.ac.jp
K. Kawai
Department of Radiology, Faculty of Medical Sciences,
University of Fukui, Fukui, Japan

respectively. Finally, we evaluated the concordance ofparameters between gated MPS and gated CMR by %difference and Bland–Altman plot analysis.
Results LVEF showed favorable concordance in both restand exercise conditions (% differences were around 10%).
PER, PFR and TTPF also showed good concordances inrest conditions, under 32-frame gated collections particularly (% differences were around 10%). In exercise conditions, although the concordances were relatively good,certain variances were noted (% differences were around
20–25%). Regarding left ventricular volumes, the concordance were worse in both conditions (% differences werearound 30–40%).
Conclusions In quantifying of left ventricular function
parameter, gated CMR provides similar quantitative values
comparing with gated MPS except for ventricular volumes
in rest conditions. In contrast, there were certain variations
except for LVEF in exercised examinations. When wefollow patients by the same cardiac parameters with CMR
and MPS, using parameters across the two modalities
proved to be possible under rest condition. However, it islimited at exercise condition.
Keywords Left ventricular function parameters 
Gated MPS  Gated CMR  The agreement

Introduction
Measurement of left ventricular systolic function (SFx) as
assessed by left ventricular (LV) volumes and ejection
fraction (EF) is a powerful and reliable method for theprediction of long-term prognosis in various heart diseases[1–4]. In addition, left ventricular diastolic dysfunction(DFx) is usually recognized earlier than abnormalities of

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Ann Nucl Med (2012) 26:147–163

other parameters in many cardiac diseases, including coronary artery disease (CAD), congestive heart failure(CHF), hypertrophic cardiomyopathy, valvular heart disease, diabetes mellitus, and hypertension [5–10]. Therefore, assessing left ventricular diastolic function is also
important in determining the effective treatment strategy.
Conventionally, echocardiography, conventional planar
equilibrium radionuclide angiography (ERNA), and cardiac-gated blood-pool scintigraphy (GBPS) have been
widely used for the evaluation of DFx [11–13]. In recent
years, in addition to myocardial perfusion analysis, gatedmyocardial SPECT (MPS) is widely used assessing SFx,
DFx, end-diastolic volume (EDV) and end-systolic volume(ESV) [10, 14–20]. It has also worth for determining
prognosis [2].
As an alternative method, cardiac MRI (CMR) examination has become a convenient procedure to diagnose
cardiovascular disease with the improvement of imaging
techniques and the speed of data processing of image
operations [20–26]. It has excellent temporal resolution andalso helps to visualize coronary arteries, myocardial perfusion and myocardial viability [27–32]. In addition,
because CMR does not rely on geometric assumptions ofleft ventricular shape, it has been used as the standard ofreference for validation of gate MPS in assessment ofcardiac volumes and function [33–35]. Thus, CMR will be
more frequently used as an important method by routine
practice like gated MPS. Therefore, it is extremely

important to evaluate the compatibility of quantitative
parameter across both methods, MPS and CMR. However,a few studies addressed how values of left ventricularfunction parameters obtained by the two different modalities are concordant with each other [36–38].
To our knowledge, the current study is the first researchcomparing the left ventricular function parameters including diastolic function parameter (DFx) by two different
modalities, MPS and CMR, directly at both rest andexercise. The purpose is to evaluate the concordance of left
ventricular parameters including DFx obtained by MPS andCMR in healthy normal volunteers. In addition, we evaluated how much error ranges we should take into accountin the follow-up with functional parameters across the twodifferent modalities.

Materials and methods
Subjects
This investigation complied with the tenets of the Declaration of Helsinki promulgated in 1964 and was approvedby the Institutional Review Board. Ten healthy volunteers(ten men, mean age, 30.4 ± 4.2 years) participated in the
study. None had a history of hypertension, diabetes, valvular disease, or other cardiac diseases. All volunteers wererecruited and provided written informed consent. The

Table 1 The % differences between gated SPECT and gated MRIFrame

EDV (ml)

ESV (ml)

LVEF (%)

PER (EDV/s)

PFR (EDV/s)

TTPF (ms)Rest
Gated SPECT

Gated MRI

Difference (%)

Gated SPECT

Gated MRI

Difference (%)

892.0 ± 24.0

127.4 ± 15.0

28.3 ± 17.8

82.2 ± 22.4

114.5 ± 15.7

40.1 ± 29.0

16
32

92.0 ± 21.0
95.5 ± 26.9

122.4 ± 20.1
118.8 ± 16.0

27.6 ± 14.7
25.0 ± 14.2

84.6 ± 25.3
86.6 ± 24.7

109.6 ± 14.8
105.7 ± 11.1

38.6 ± 26.2
34.5 ± 19.5

8

38.6 ± 18.1

58.0 ± 12.7

36.9 ± 18.7

31.8 ± 14.1

35.1 ± 15.7

31.1 ± 15.9

16

32.9 ± 11.6

51.4 ± 12.3

39.7 ± 17.5

29.4 ± 14.1

30.9 ± 13.6

26.3 ± 22.8

32

30.9 ± 15.6

48.7 ± 9.542.2 ± 18.7

27.0 ± 13.4

27.0 ± 10.5

24.2 ± 18.3

8

59.6 ± 8.5

54.7 ± 7.0

8.2 ± 5.2

62.8 ± 9.1

60.6 ± 6.7

8.5 ± 6.6

16

65.0 ± 5.6

58.2 ± 6.1

11.5 ± 7.4

66.7 ± 8.8

65.2 ± 6.3

11.0 ± 8.6

3268.9 ± 7.3

59.0 ± 5.4

13.3 ± 5.1

70.3 ± 9.1

67.9 ± 4.6

11.5 ± 7.88

2.7 ± 0.6

3.0 ± 0.5

17.3 ± 10.2

3.4 ± 1.0

3.9 ± 0.7

21.7 ± 12.4

16

3.1 ± 0.5

3.5 ± 0.4

16.3 ± 12.4

3.7 ± 0.9

4.2 ± 0.6

25.5 ± 11.6

32

3.5 ± 0.6

3.7 ± 0.4

11.7 ± 7.7

4.1 ± 1.1

4.1 ± 0.4

21.1 ± 15.88

2.4 ± 0.6

2.6 ± 0.6

20.7 ± 16.8

3.4 ± 1.2

3.4 ± 1.0

17.5 ± 13.6

16

2.9 ± 0.9

3.1 ± 0.5

18.6 ± 15.2

3.5 ± 0.9

3.7 ± 0.8

23.0 ± 10.5

32

3.1 ± 0.8

3.0 ± 0.6

11.5 ± 8.9

4.5 ± 1.4

4.0 ± 1.0

21.4 ± 16.3

8168.2 ± 29.9

145.9 ± 24.5

17.7 ± 14.2

149.5 ± 43.0

154.4 ± 19.4

24.2 ± 11.9

1632

153.3 ± 20.0
150.4 ± 27.4

145.2 ± 25.1
149.7 ± 40.1

20.1 ± 7.1
10.6 ± 4.2

148.2 ± 56.3
137.9 ± 60.5

135.4 ± 35.7
139.0 ± 48.5

35.0 ± 12.3
26.9 ± 17.4

Data are expressed as mean ± SD

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ExerciseAnn Nucl Med (2012) 26:147–163

1
*

a 150

**

b

***

**
***

Rest

Exercise

***

***

Rest

Exercise

Rest

Exercise

80
60

100

ESV (ml)

EDV (ml)Fig. 1 Parameters by MPS (1)and CMR (2). Each quantitative
parameter was demonstrated
at rest and at exercise,respectively. EDV (a), ESV (b),LVEF (c), PER (d), PFR (e) and
TTPF (f). Each bar represents
the mean ± SD

149

50

40
20

0

LVEF (%)

90

Exercise

***

***

*

d

6.0

PER (EDV/sec)

c

0
Rest

60

30

4.0

2.0

0

0

6.0

Exercise

***

***

f
250
200

TTPF (msec)

PFR (EDV/sec)

Rest

*

e

*

4.0

2.0

150
100
50

0
Rest

: 8 frame,

experiments and informed consent form were approved by
the Institutional Review Board of the School of Medicineof Miyazaki University.
Exercise protocol
Both multi-stage exercise MPS and CMR examinations
using a bicycle ergometer were performed from 90 W andincreased by 30 W every 3 min. Accepted endpoint for the
exercise test was achievement of 85% of the target heartrate. All exercise MPS were done at SPECT laboratory and
CMR examinations were done in the room next to the MRI
room. Both gated MPS and gated CMR started within
5 min after the exercise tests completion.
Gated MPS
A dose of 600 MBq 99mTc-tetrofosmin (Nihon Mediphysics Co., Ltd., Nishinomiya, Japan) was administered0

Exercise: 16 frame,: 32 frame

intravenously at rest under fasting conditions. Forty minutes after the injection of 99mTc-tetrofosmin, electrocardiography (ECG)-gated MPS at rest images were acquiredwith a 2-detector 180° camera (E-cam, Siemens Medical
System, USA) equipped with cardiac collimators using
elliptic 360° acquisition with 46 projections at 20 s per
projection and a zoom factor of 1.45 and stored in a
64 9 64 matrix; ECG-gated 32-frame per R–R interval
SPECT data were acquired. The exercise studies were
performed a few hours after the rest studies with same dataacquisition protocol. A dose of 600 MBq 99mTc-tetrofosmin was intravenously injected at peak exercise, and stresslasted for another minute. The acquisition time of both restand exercise study were 20 min.
Both MPS image reconstruction and data analysis wereconducted by one well-trained technologist. The 32-frame
dataset was transferred to a workstation system (Siemens
Medical System, USA), where the data were combined into
8- and 16-frame gated data. The projection data were

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150
Fig. 1 continued

Ann Nucl Med (2012) 26:147–163

2
a

**

*

150

b

**

**

Rest

Exercise80

ESV (ml)

EDV (ml)

60
100

50

40
20
0

0
Exercise

*

**

80
60

LVEF (%)

d 6.0
PER (EDV/sec)

c

Rest

40

20

Rest

2.0

Rest

Exercise

Rest

Exercise

f 250

*

200

TTPF (msec)

PFR (EDV/sec)

4.0

Exercise

4.0

2.0

150
100
50
0

0
Rest

Exercise: 8 frame,

reconstructed into tomographic trans-axial images using afiltered back-projection method with a ramp filter followedby 2-dimensional Butterworth filtering (order, 5; cut-off
frequency, 0.6 cycle/pixel on a 0–1 scale) [14, 15]. Neither
attenuation correction nor scatter correction was performed.
The left ventricular volume and LVEF were calculated
automatically from 8, 16, and 32 frame-gated data using
QGS program (Cedars-Sinai Medical Center, Los Angeles,
CA, USA) [14, 15]. Then we extracted value of left ventricular volume in each phase as a text file. After theseprocedures, we calculated TTPF, PER and PFR using
values of ventricular volume with curve differential calculus software VCDiff software (VCDiff, Version 3.1,
FUJIFILM RI Pharma CO., Ltd., Tokyo, Japan) [19].
Gated CMR
Gated CMR examinations were performed within a few daysof gated MPS examinations. Images were acquired with a

123

***

0

0

e 6.0

*

: 16 frame,: 32 frame

1.5-T whole-body MR system (Vantage: Toshiba Medical
System, Tokyo, Japan) using a quadrature phased-array
body coil (Torso SPEEDER coil: Toshiba Medical System,
Tokyo, Japan) [39], prospective electrocardiography triggering, and breath holding. The acquisition time of both restand exercise study were 10 min. To detect relevant changes
in hemodynamic parameters during the examination, heart
rate were monitored and documented. The position of theheart was determined with a localizer sequence [single-shot
two-dimensional steady-state precession sequence (SSFP)[22, 39], repetition time ms/echo time ms of 3.7/1.9, flip
angle of 70°, 6-mm section thickness, 360 9 360 field ofview, 128 9 256 matrix], and imaging planes were adjusted
to obtain standard long- and short-axis views. Subsequently,
SSFP cine MR imaging was performed in the LV from thebase to the apex, with 8- to 10-mm thick sections and 5-mm
gap in the short-axis orientation.
In the current study, a segmented SSFP two-dimensionalsequence was modified to vary temporal resolution. The

Ann Nucl Med (2012) 26:147–163

151

Table 2 The agreement range between two methods (Bland–Altman
plot analysis)
Parameters

EDV (ml)

ESV (ml)

LVEF (%)

PER (EDV/s)

PFR (EDV/s)

TTPF (ms)Frame

Rest-agreement
range

Exercise-agreement
range

Lower

Upper

Lower

Upper

8

-82.3

11.4

-11.2

70.0

16

-25.0

76.3

-31.1

75.1

32

-72.3

30.0

-38.1

70.5

8

-0.93

39.8

-19.4

26.0

16

-6.4

43.4

-18.7

19.7

32

-40.0

5.0

-16.1

17.9

8

-11.5

1.5

-17.1

12.8

16

-17.6

4.0

-19.8

16.7

32

2.0

18.0

-22.3

17.5

8

-0.81

1.26

-0.90

1.85

16

-0.40

1.20

-1.10

2.30

32

-1.02

0.66

-1.92

1.95

8

-0.76

1.22

-1.66

1.66

16
32

-1.39
-1.01

1.69
1.14

-1.34
-3.34

1.79
2.41
37.4

8

-94.3

49.6

-7.66

16

-74.2

58.1

-73.4

68.0

32

-54.6

56.0

-74.8

48.0

acquisition was segmented to acquire several lines of data
per image during each cardiac cycle to keep imaging times
within a reasonable breath-hold period.
To investigate the influence by number of gated frames
per R–R cycles, various data were collected, where thenumber of frames per R–R cycle was 8, 16 and 32. Echotrain length for segmented data acquisition was set to 16,
which resulted in frame durations of 60 ms. The typicalparameter settings were approximately 360 9 360-mm
field of view with 128 9 192 matrix. The breath-hold time
for data acquisition was 14 s for the number of frames per
R–R cycle of 30 ms.
Acquired data were analyzed by commercially available
software (AZE Virtual Place, Version 3.0, AZE, Tokyo,
Japan) with separately dedicated workstation. Using a midventricular image as a reference, window level settings
were done to optimize contrast between blood pool andmyocardium, and they were applied to all images of slices.
In all normal volunteers, high image quality with excellent
contrast between blood pool and myocardium wasachieved, which facilitated image segmentation. Both theend-cardiac and cardiac contours were manually drawn on
end-diastolic and end-systolic short-axis images by thesame radiologist. To derive LV volume serially, contoursof cardiac lumen were propagated at every tomographic
slice. Papillary muscles were assigned to the LV lumen
and, therefore, ignored.

The left ventricular volumes were thus obtained using
the modified Simpson’s method by summing the crosssectional areas contained by the endocardial borders of all
short-axis slices included in the analysis [33]. For calculating left ventricular function parameters, we used bothleft ventricular volume curve obtained by CMR and thecurve differential calculus software (VCDiff, Version 3.1,
FUJIFILM RI Pharma CO., Ltd., Tokyo, Japan).
Data analysis
Before analyzing the concordance of quantification by two
different modalities, we investigated the reproducibility ofinter and intra-observers in all parameters. Namely, we
calculated the % differences in each parameter by observer
1 and by observer 2, respectively. We calculated % difference of intra-observer by dividing the difference of 1stand 2nd value with 1st value. Similarly, we calculated %difference for inter-observer by dividing the difference of
1st observer’s value and 2nd observer’s value with 1st
observer’s value. Mean of ten subjects was calculated byeach frame conditions for every parameter.
To evaluate the concordance of parameter’s quantification by two different modalities, we calculated % difference by dividing the difference of CMR parameters and
MPS parameters by MPS parameters for each corresponding parameter. We also compared the value of eachparameter among three different gated conditions. Statistical analysis was conducted by Bonferroni multiple comparison test after Friedman test. Statistically, a p value of\0.05 was considered to be significant. Finally, the degreeof data concordance between the gated MPS and gated
CMR was evaluated by Bland–Altman analysis [40].
Limits of concordance were demonstrated by mean values ± 2SD. Statistical analyses were conducted using
Prism 4 (GraphPad Software Inc., San Diego, CA, USA).

Results
Physiological parameters during MPS and CMR
All examinations were performed safely and appropriately.
No participants showed ST-segment depression or typicalischemic chest pain during exercise tests. The physiologicalparameters (mean heart rate, systolic blood pressure and diastolic blood pressure) during MPS were 70.3 ± 14.3 bpm,
116.2 ± 11.1 mmHg and 65.5 ± 8.0 mmHg in the rest study
and were 91.6 ± 14.4 bpm, 140.7 ± 14.4 mmHg and70.8 ± 8.2 mmHg in the exercise study. Similarly physiological parameters (mean heart rate, systolic blood pressureand diastolic blood pressure) during CMR were 71.2 ±10.9 bpm, 115.3 ± 10.3 mmHg, and 67.6 ± 8.7 mmHg in

123

152

a
90
60
30

+11.4

0
-30

-35.4

-60

-82.3

-90
60

90

150

120

EDV (g SPECT)-EDV (g MRI) (ml)8-frame gated
EDV (g SPECT)-EDV (g MRI) (ml)Fig. 2 Bland–Altman plots
showing the agreement between
gated MPS and gated CMR.
EDV (a rest, b exercise), ESV(c rest, d exercise), LVEF
(e rest, f exercise), PER (g rest
study, h exercise), PFR (i rest,
j exercise) and TTPF (k rest,l exercise)

Ann Nucl Med (2012) 26:147–163

b
90
60
30

29.4
0

-60
-90
60

+39.8
25

19.3
0

-0.93
-25
-50
150

ESV (g SPECT)-ESV (g MRI) (ml)

ESV (g SPECT)-ESV (g MRI) (ml)

50

120

20

+1.5

0

-4.9
-11.5

-30
30

90

60

Mean LVEF (g SPECT and g MRI) (%)

the rest study. Similarly, they were 92.3 ± 16.7 bpm,
137.3 ± 12.8 mmHg and 68.3 ± 10.4 mmHg in the exercise
study. These values did not statistically significantly differ
compared with the parameters of MPS.
Left ventricular function parameters measured by MPS
None of participants showed perfusion abnormalities at
gated MPS. In comparison of various left ventricularparameters among three kinds of gated conditions at rest,
EDV, LVEF, PER and PFR in 8 frame-gated studies were123

LVEF (g SPECT)-LVEF(g MRI) (%)

LVEF (g SPECT)-LVEF(g MRI) (%)

30

-20

150

50

+26.0
25

3.30
0

-19.4

-25
-50
60

90

120

150

Mean ESV (g SPECT and g MRI) (ml)

e

-10

120

d

Mean ESV (g SPECT and g MRI) (ml)1090

Mean EDV (g SPECT and g MRI) (ml)

c

90

-11.2

-30

Mean EDV (g SPECT and g MRI) (ml)

60

+70.0

f
30
20

+12.8

10
0

-2.18

-10
-20

-17.1

-30
30

60

90

Mean LVEF (g SPECT and g MRI) (%)

significantly lower than those of 32-frame gated studies.
Both LVEF and PER in 8-frame gated studies were also
lower than those of 16-frame gated conditions. The valueof ESV in 8-frame gated study was significantly higher
than that of 32-frame gated study. No significant difference
was noted for TTPF. With regard to exercise study, similartendencies were noted. In addition, ESV in 16-frame gatedconditions was significantly higher than that in 32-frame
gated study. The value of PFR in 32-frame gated study was
also significantly higher than that of 16-frame gated study(Table 1; Fig. 1-1).

Ann Nucl Med (2012) 26:147–163

153

Fig. 2 continued

-

2.0

+1.26

1.0
0

0.23

-1.0

-0.81

-2.0
-3.0
0

2.0

4.0

6.0

Mean PER (g SPECT and g MRI) (EDV/sec)

i
6.0
3.0

+1.22
0.23

0

-0.76
-3.0
-6.0
0

2.0

4.0

6.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

k
250
150

+49.6
-22.3

50
0
-50

-94.3

-150
250
80

160

240

Mean TTPF (g SPECT and g MRI) (msec)

Left ventricular function parameters measured by CMR
In comparison of various left ventricular parameters among
three kinds of gated condition at rest, LVEF, PER and PFR
in 8 frame-gated studies were significantly lower than thoseof 32-frame gated studies. In addition, PER in 8 framegated study was lower than that of 16-frame gated condition. With regard to ventricular volumes, both EDV and
ESV in 8-frames gated studies were significantly higher
than those of 32-frame gated studies. No significant difference was noted in TTPF. Although similar tendencies

PER (g SPECT)-PER (g MRI) (EDV/sec)

3.0

PFR (g SPECT)-PFR (g MRI) (EDV/sec)g

TTPF (g SPECT)-TTPF (g MRI) (msec)

TTPF (g SPECT)-TTPF (g MRI) (msec)

PFR (g SPECT)-PFR (g MRI) (EDV/sec)

PER (g SPECT)-PER (g MRI) (EDV/sec)

8-frame gated

h
3.0
+1.85

2.0
1.0
0

0.46

-1.0

-0.9

-2.0
-3.0
0

2.0

4.0

6.0

Mean PER (g SPECT and g MRI) (EDV/sec)

j
6.0
3.0

+1.66

0

0.0

-3.0

-1.66

-6.0
0

2.0

4.0

6.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

l
250
150
+37.4
50
0
-50

14.9
-7.66

-150
-250
80

160

240

Mean TTPF (g SPECT and g MRI) (msec)

were noted in the exercise conditions, there was no statistical significance in PER and PFR (Table 1; Fig. 1-2).
Reproducibility of quantification intra-observers
and inter-observers
The reproducibility of quantification of all parameters
except ventricular volumes in both methods was good,showing % differences of smaller than 5.0%. Nevertheless,% differences of ventricular volumes were smaller than
6.0% (Supplemental table 1-1, 1-2).

123

154

Ann Nucl Med (2012) 26:147–163

Fig. 2 continued

a
90
60

+76.3

30

30.4

0
-30

-25.0

-60
-90
60

90

120

150

EDV (g SPECT)-EDV (g MRI) (ml)

EDV (g SPECT)-EDV (g MRI) (ml)16-frame gated

b
90
60

-30

-90
60

90

120

150

d

50

+43.4

25

18.5

0

-6.4

-25
-50
60

90

120

150

ESV (g SPECT)-ESV (g MRI) (ml)

ESV (g SPECT)-ESV (g MRI) (ml)

-31.1

-60

Mean EDV (g SPECT and g MRI) (ml)

c

50

20

0

-6.8

-10
-20

-17.6

-30
30

90

60

Mean LVEF (g SPECT and g MRI) (%)

Percent difference (% difference) of left ventricularfunction parameter between MPS and CMR
The values of % difference in LVEF were about 10% in
both rest and exercise study. They were from 10 to 20% for
PER, PFR, and TTPF at rest. However, they tended to behigher at exercise around 20–25%. In particular, % difference of EDV and ESV was approximately 25–40% in
both rest and exercise study (Table 1).
Bland–Altman plot analysis
At rest condition, in TTPF, 32-frame collection showed
the best agreement. In contrast, LVEF showed the best

LVEF (g SPECT)-LVEF(g MRI) (%)

30

+3.96

0.5

0
-25

-18.7
-50
60

90

120

150

Mean ESV (g SPECT and g MRI) (ml)

e

10

+19.7

25

Mean ESV (g SPECT and g MRI) (ml)
LVEF (g SPECT)-LVEF(g MRI) (%)

22.0

0

Mean EDV (g SPECT and g MRI) (ml)

123

+75.1

30

f
30
20

+16.7

10
0

-1.53

-10
-20

-19.8
-30
30

60

90

Mean LVEF (g SPECT and g MRI) (%)

agreement range in 8-frame collection despite deviationof distribution. As for PER and PFR, no prominent
differences were noted between 8-frame collection and
32-frame collection. Also in ESV and EDV, the agreement was not so different among three kinds ofcollection.
At exercise conditions, the agreement range tended to
be wider than those in rest conditions. Although certain
tendency was not noted, agreement ranges of EDV,LVEF, PER and TTPF were narrower in 8-frame gatedcollections. As for ESV, 32-frame collection showed thebest agreement. In PFR, both 8-frame collection and
16-frame collection showed similar agreement range(Table 2; Fig. 2).

Ann Nucl Med (2012) 26:147–163

155

Fig. 2 continued

3.0
2.0

+1.2

1.0

0.4

0
-1.0

-0.4

-2.0
-3.0
0

2.0

6.0

4.0

PER (g SPECT)-PER (g MRI) (EDV/sec)

g

h
3.0
2.0

6.0
3.0

+1.69
0.15

0

-1.39

-3.0
-6.0
0

2.0

6.0

4.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

k
250
150

+58.1
50
0
-50

-8.1

-74.2

-150
-250

80

240
160
Mean TTPF (g SPECT and g MRI) (msec)

PFR (g SPECT)-PFR (g MRI) (EDV/sec)

i

+2.30

1.0
0

0.56

-1.0

-1.10

-2.0
-3.0
0

2.0

4.0

6.0

Mean PER (g SPECT and g MRI) (EDV/sec)

Mean PER (g SPECT and g MRI) (EDV/sec)

TTPF (g SPECT)-TTPF (g MRI) (msec)

TTPF (g SPECT)-TTPF (g MRI) (msec)

PFR (g SPECT)-PFR (g MRI) (EDV/sec)

PER (g SPECT)-PER (g MRI) (EDV/sec)

16-frame gated

j
6.0

+1.79

3.0

0.22
0

-1.34

-3.0
-6.0
0

2.0

4.0

6.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

l
250

+68.0
150
50
0
-50

2.8

-73.4

-150
-250

80

160

240

Mean TTPF (g SPECT and g MRI) (msec)

Representative case

Discussion

The representative case included a 32-year-old man in
healthy condition. In the rest study, values of % difference were more than 30% in EDV and were more than
50% in ESV. In contrast, it was smaller than 10% in
LVEF. In diastolic parameters, they were smaller than25%. Similar tendencies were noted in the exercise study.
Namely, values of % difference in ventricular volumes
were about 30–60%. In both systolic and diastolic
parameters, values of % difference were smaller than 25%(Table 3; Fig. 3).

In evaluating the agreement of left ventricular function
parameters obtained by gated MPS and gated CMR, thevalues of LVEF showed the best concordance among allparameters. The values of % difference were around 10%
in both rest and stress conditions and the agreement ranges
were ±10% in rest and ±20% in stress conditions. These
results were consistent with the previous report in bypass
grafting patients in rest conditions by Mesquita et al. [37].
In the current study, % difference of 8-frame gated wassmaller than that of 32-frame gated study (8.2 vs. 13.3) and

123

156

Ann Nucl Med (2012) 26:147–163

Fig. 2 continued

a
90
60

+30.0

30
0
-30

-23.3

-60

-72.3

-90
60

90

150

120

EDV (g SPECT)-EDV (g MRI) (ml)

EDV (g SPECT)-EDV (g MRI) (ml)32-frame gated

b
90
60

-30
-60

25

+5.0
0

-17.8
-25

-40.0
-50
150

ESV (g SPECT)-ESV (g MRI) (ml)

ESV (g SPECT)-ESV (g MRI) (ml)

50

120

60

+18.0
+10.0

0

+2.0
-10
-20
-30
90

60

Mean LVEF (g SPECT and g MRI) (%)

the agreement range was relatively narrower (-11.5 to 1.5
vs. 2 to 18%). Similar pattern was also noted under exercise condition. The following reason is speculated. In
determining end-systolic point, 8-frame collection is simpler than other collection conditions, because of fewer
systolic points. In 16- or 32-frame collections, the decisionof end-systolic point could be relatively unstable, owing tomany neighboring systolic points. Consequently, % difference in ESV calculation by 8-frame collection wasconsidered to be smaller than other collections. Because
LVEF calculation is influenced by ESV, smaller % difference in ESV calculation seemed to explain the smaller% difference in LVEF by 8-frame collection. However,
8-frame gated analysis has drawback of underestimation

123

LVEF (g SPECT)-LVEF(g MRI) (%)

LVEF (g SPECT)-LVEF(g MRI) (%)

e

30

120

150

d
+17.9

25
0

0.92
-25

-16.1
-50
60

90

120

150

Mean ESV (g SPECT and g MRI) (ml)

30

10

90

50

Mean ESV (g SPECT and g MRI) (ml)

20

-38.1

-90

Mean EDV (g SPECT and g MRI) (ml)

c

90

16.1

0

Mean EDV (g SPECT and g MRI) (ml)

60

+70.5

30

f
30

+17.5

20
10
0

-2.39

-10

-22.3

-20
-30
30

60

90

Mean LVEF (g SPECT and g MRI) (%)[41, 42] and the phenomenon was also confirmed in ourstudy. In considering the reliability of calculated values
and also the compatibility between two different modalities, 32-frame gated study would be recommended as
routine examination.
Judging from values of % differences and Bland–
Altman plots analysis, the agreement of left ventricularvolumes were relatively poor than other parameters. In
particular for EDV, the changes of ventricular volumes
following the changes of frame number showed an inverse
pattern, respectively. Ventricular volumes were known tobe underestimated by MPS compared to CMR [36, 43]. We
confirmed similar tendency in the current study. The
membranous part of the septum and the atrioventricularAnn Nucl Med (2012) 26:147–163

157

Fig. 2 continued

2.0

+0.66

1.0
0

-0.18
-1.0

-1.02

-2.0
-3.0
0

2.0

4.0

6.0

Mean PER (g SPECT and g MRI) (EDV/sec)

i
6.0
3.0

+1.14
0.07

0

-1.01
-3.0
-6.0
0

2.0

4.0

6.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

k
250
150

+56.0
0.7

50
0
-50

-54.6
-150
-250
80

160

240

Mean TTPF (g SPECT and g MRI) (msec)

valve plane do not contain myocardium and are therefore
not visible in MPS images [36]. Due to such differences of
depiction methods for cardiac lumen, the underestimationof left ventricle in MPS should be unavoidable. Particularly
in EDV, the agreement ranges were around ±50 ml in thecurrent results. Although the range was smaller than previous reports [37], the agreement was not sufficient.
Both PFR and TTPF are conventional DFx parameters[10, 44, 45]. Although the agreement range was similar,
value of % difference of PFR was better in 32-frame compared with 8-frame gated condition at rest study. As forPER (g SPECT)-PER (g MRI) (EDV/sec)

3.0

PFR (g SPECT)-PFR (g MRI) (EDV/sec)g

TTPF (g SPECT)-TTPF (g MRI) (msec)

TTPF (g SPECT)-TTPF (g MRI) (msec)

PFR (g SPECT)-PFR (g MRI) (EDV/sec)

PER (g SPECT)-PER (g MRI) (EDV/sec)

32-frame gated

h
3.0

+1.95

2.0
1.0
0

-0.02
-1.0
-2.0

-1.92

-3.0
0

2.0

4.0

6.0

Mean PER (g SPECT and g MRI) (EDV/sec)

j
6.0
3.0

+2.41

0

-0.46
-3.34

-3.0
-6.0
0

2.0

4.0

6.0

Mean PFR (g SPECT and g MRI) (EDV/sec)

l
250
150

+48.0
50
0
-50

-13.4
-74.8

-150
-250
80

160

240

Mean TTPF (g SPECT and g MRI) (msec)

TTPF, the agreement was best in 32-frame study (% difference was 10.6 and agreement range was from -54.6 to
56.0 ms). However in exercise studies, % differences of PFR
of each condition were around 20% and agreement ranges
were relatively wider than those of under rest conditions.
Similarly, the % differences of TTPF were around 25 to 35%
and the agreement ranges got deteriorated in both 16- and
32-frame collections. We should keep in mind that concordance of diastolic parameters deteriorates at exercise.
In comparing 32-frame collection with 8-frame collection only about the agreement, there might not be major

123

158

Ann Nucl Med (2012) 26:147–163

Table 3 Parameters of representative caseParameters

EDV (ml)

ESV (ml)

LVEF (%)

PER (EDV/s)

PFR (EDV/s)

TTPF (ms)

Phase

Rest

Exercise

SPECT

MRI

% Difference

SPECT

MRI

% Difference

8

82.3

130.7

58.8

72.2

100.0

38.5

16

85.2

120.8

41.8

72.5

93.1

28.4

32

89.1

115.9

30.1

71.0

90.3

27.2

8

31.1

54.3

74.6

25.8

42.9

66.3

16

33.1

49.4

49.2

24.3

35.8

47.3

32

32.0

46.9

46.6

17.9

24.5

36.9

8
16

62.2
61.5

58.3
59.1

6.3
3.9

64.2
66.5

57.0
61.2

11.2
8.0

32

63.0

59.5

5.6

75.1

68.6

8.7

8

2.79

3.05

9.3

5.04

4.38

13.1

16

3.82

3.86

1.0

4.98

4.23

15.1

32

2.77

2.94

6.1

5.41

5.12

5.4

8

2.38

2.62

10.1

3.82

3.69

3.4

16

2.51

3.11

23.9

3.75

3.93

4.8

32

2.53

2.88

13.8

4.52

5.02

11.1

8

124

129

4.0

171

154

9.9

16

129

155

20.1

168

204

21.4

32

147

134

8.8

186

187

0.5

Fig. 3 Automaticallydetermined cardiac lumen invarious gated condition in MPS(1) and time–volume curves
with differential curve aredemonstrated (2). Manuallydrawn cardiac lumen in various
gated condition in CMR (3) andtime–volume curves withdifferential curve aredemonstrated (4)MPS

1Exercise

Rest
EDV

ESV

EDV

ESV

8 frame

16 frame

32 frame

difference. However, 8-frame collection has a problem inquantification. Although the values of PFR at rest obtainedby either 16- or 32-frame gated MPS were almost equal toprevious GBPS or MPS examinations [44, 46–48], underestimation was observed in both modalities by 8-frame
collection in the current study. As stated above, using

123

8-frame instead of 32-frame gated SPECT data causes
temporal undersampling [42]. Because PFR is denoting the
maximum value of the derivative of the time–volume
curve, the inaccurate determination of the end-systolicpoint using 8-frame gated SPECT was considered to be
major causative reason of underestimation. As for value ofAnn Nucl Med (2012) 26:147–163
Fig. 3 continued

159

2

MPS
Rest

Exercise

8 frame

16 frame

32 frame

TTPF, it is reported to be relatively stable irrespective ofage, sex, heart rate [10, 44], or numbers of gated-frame[44]. However, in the current study at rest, the value

obtained by 8-frame collection is longer than that of
32-frame collection in MPS. Such tendency was not always
noted in CMR in rest condition. Nevertheless, more

123

160
Fig. 3 continued

Ann Nucl Med (2012) 26:147–163

CMR

3

Rest
EDV

Exercise
ESV

EDV

ESV

8 frame

16 frame

32 frame

number of frame data collections would be desired in orderto obtain DFx parameters accurately by improving temporal resolution [49].
Interestingly, the value of PFR increased by around
30–40% at exercise compared to rest condition at 32-frame
gating. Although normal value ranges of PFR at exercise
condition had not been established, the increase rate might
be related to exercise capacity [8]. However, the value at
8-frame study was lower than that of 32-frame data under
exercise conditions. Therefore, the PFR value at 8-frame
study was also considered to be underestimated similarly asat rest condition. As for values of TTPF at exercise condition, they were relatively shorter than those in rest condition. Although normal value ranges of TTPF at exercise
condition have not been ensured either, they were around
140 ms by 32-frame gating and were approximately
150 ms by 8-frame gating. Considering quantitative accuracy and relatively good agreement, 32-frame gated condition would be recommended as routine procedure inmonitoring DFx with both modalities.
One of the significant limitations in the current study isthe difference of data acquisition time. Namely, CMR takes
about 10 min and MPS takes about 20 min, which resulted
in differences of recovery from exercised status and degreeof loaded stress during imaging time. In addition, the differences in the physical conditions of volunteers between
the two studies could be an additional influential factor. At
the same time, because exercise test could not be carriedout in MRI scanning room, there might be an individual

123

difference in scan initiation time. Unification of the exercise protocol of CMR is desired in future. The degree ofagreement will improve, if we resolve the above problems.
In SPECT data acquisition, we adopted 360° angularsampling techniques in order to reduce geometric distortion[50]. In addition, in the evaluation of detecting significant
CAD in the Japanese study, 360° database showed the best
diagnostic performance [51]. Although the apparent difference has not been reported between both 180° and 360°
collection about an LVEF or ESV, EDV was relatively
lower in 360° collection [52]. Therefore, gated SPECT databy 180° collection also may be necessary in discussing
degree of the agreement with the MRI in future study.
From a clinical point of view, institutions where CMR isused in myocardial examinations will increase continuously because it can give information, such as coronary
vessel stenosis, not to be evaluated with MPS [32].
Opportunities adopting each other’s quantitative data as
reference will also increase. Based on the current results,
both SFx and DFx could be monitored jointly by CMR or
MPS in rest conditions. However, in exercise conditions,
we should use quantitative parameters, taking into consideration the agreement range between two methods,
owing to the dissociation of image acquisition time. In
future, the collection time of SPECT will be shortened byrecent progression of instrument such as semiconductor
detector gamma camera [53, 54]. Further study with newdevices is desired to confirm the improvement of theagreement of exercise stress data between CMR and MPS.

Ann Nucl Med (2012) 26:147–163

161

Fig. 3 continued

4

CMRI
Rest

Exercise

8 frame

16 frame

32 frame

Conclusion
We evaluated agreement of left ventricular function
parameters obtained in MPS and CMR of healthy volunteers.
LVEF showed favorable agreement in both rest andexercise conditions. Although diastolic parameters also

showed good concordance at 32-frame gating in rest study,
they showed certain differences at exercise examination.
Regarding left ventricular volumes, the concordances were
worse in both rest and exercise conditions.
When we follow patients by the same cardiac parameters except for ventricular volumes with CMR and MPS at

123

162

rest conditions, using parameters across the two modalities
proved to be feasible. However, the use is limited at
exercise condition.

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